Provider Demographics
NPI:1518280676
Name:CLC, INC
Entity Type:Organization
Organization Name:CLC, INC
Other - Org Name:CLEAN LIVING CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:PH, D
Authorized Official - Phone:503-515-5247
Mailing Address - Street 1:8002 NE HIGHWAY 99
Mailing Address - Street 2:PMB 617
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8876
Mailing Address - Country:US
Mailing Address - Phone:503-515-5247
Mailing Address - Fax:360-718-7949
Practice Address - Street 1:1714 NE 72ND CIR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-0586
Practice Address - Country:US
Practice Address - Phone:503-515-5247
Practice Address - Fax:360-718-7949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility